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As a hospital-based physician, the contract negotiations between the Minnesota Nurses Association and six Twin Cities hospital systems make me feel like a child in the middle of a divorce proceeding.

I admire nurses and the work that they do. I consider them to be my colleagues; some of them are my friends. Though I’m tiring of all the lawn signs, nurses do care for us, and the work they do in the hospital can be physical demanding, mentally challenging and emotionally intense. By necessity they work the bad hours — nights, weekends, holidays — a sacrifice of sorts.

But I can also appreciate the financial pressures faced by those in leadership positions within the business of health care. Financially speaking, the current American health care is killing us.

The Minnesota Department of Health announced this week that health care spending here in the L’etoile Du Nord rose to $35 billion in 2008, an increase of 5.7 percent from 2007.

What we have is a highly marketed, technology-avid health-care system that delivers average outcomes at well-above-average prices. That’s paying too much for too little, and health care leaders are in the unenviable but necessary position of having to cut costs while hopefully improving quality.

Fight over patient careSo the two sides are duking it out on billboards, websites and media spots. Both insist that their fight is all about patient care, a claim which spans the spectrum between hyperbolic and naïve. What contract negotiation isn’t, at least in part, about the money?

Who knows what’s being said behind closed doors, but here’s what being said publicly. The Minnesota Nurses Association has identified four key issues: safe RN staffing levels; proper disaster-response equipment and planning; assurances that technology will enhance patient care, not endanger it; and pension issues. The Allina Health system, a major player in the current negotiations, has identified their own four key issues: staffing, health care coverage, pension reform and wages.

Of the two items common to both parties’ list, pension issues seem primarily about the money. So let’s focus on hospital nurse staffing, which is typically a hospital’s largest single expense but also a major factor in the quality of patient care.

In a recent press release, Linda Hamilton, an RN in the Children’s Hospital System and president of the Minnesota Nurses Association (MNA), summarized the MNA’s point of view. “Twin Cities hospitals are dangerously understaffed, and our patients are needlessly suffering and sometimes even dying as a result,” Hamilton said. “As nurses, we’re tired of seeing this happen shift after shift.”

Though Hamilton’s statement is hampered by reference problems — it’s the staffing problems that are occurring shift after shift, not patients suffering and dying because of staffing — it does encapsulate the MNA’s point that when the patient load carried by an individual nurse becomes too much, the quality of patient care suffers.

Yes, health care is a business, but it’s a different kind of business: no one chooses to be ill, and to a patient (“customer”) the implications of poor nursing care (“service”) are intensely personal and can even be, in rare circumstances, life threatening. This is not a 15-minute wait on the phone to an understaffed call center in India; this is not waiting for weeks for a contractor who simultaneously bid on six jobs but only has the staff to do two jobs while the others wait.

Staffing ratios and saving moneyIt’s easy to see how having more nurses around might increase the quality of patient care, but it’s also clear that higher nurse staffing levels means increased cost. But research presented by the MNA suggest that better nurse staffing ratios can actually save money in the following ways:

• Changes in a patient’s condition can be detected and dealt with earlier.

• Substantially reduces nurse burn-out, leading to less turnover and better retention of the most experienced nurses.

• Patients are to be better prepared for discharge, leading to fewer readmissions (a known quality measure that is being aggressively targeted by hospitals).

Dr. Penny Wheeler

“Better patient outcomes and millions of dollars in savings? What hospital administrator wouldn’t jump at that?” I asked Dr. Penny Wheeler, an obstetrician/gynecologist who’s now the chief clinical officer for Allina Hospitals and Clinics.

She began her reply on a reassuring note. “By most statistics we [Minnesota] do better on quality than the vast majority of states — we’re usually ranked one or two.”

But she was reluctant to go toe-to-toe with the data cited by the MNA. To her view, the research on staffing levels and safety draws varied conclusions, and she noted that a deluge of clinical variables make it difficult to extrapolate one health care system’s experience to another entirely different system.

John Nemo, head of public relations for the MNA, sees the research as broad and persuasive. “If you look at the reality, there are far more studies in our corner saying that it [poor staffing ratios] is a problem, than there are studies in the hospitals’ corners saying, ‘Oh, it’s not a big deal.'”

Wheeler preferred to focus on what she calls the triple aim of health care: “High quality, best patient experience, at affordable costs.”

She suggested that one way to maintain (or even improve) the first two while at the same time increasing affordability is to be able to quickly staff up and down based on hospital occupancy (a very fluid dynamic in any hospital).

“You want to have the right staffing to meet the patients’ needs,” Wheeler explained, “and you want to be able to flex that staffing when the needs are less or greater.”

Currently, metro hospitals follow a system agreed upon in previous MNA contract negotiations to determine how many nurses are working on what particular ward during what particular shift. Seeing how hospital occupancy and patient acuity create a dynamic, undulating line, for affordability (ie. costs) purposes, hospitals would like to staff in a way that tightly follows that line.

Unfortunately, this is a difficult trick to pull off, which means that inevitably the hospital is sometimes overstaffed, and sometimes understaffed. Being overstaffed hampers affordability — a very legitimate concern if affordability means access to health care, a much less legitimate concern if it’s a synonym for profitability. The stress of being understaffed can be withering and falls directly on the nursing staff shoulders. A patient’s condition can deteriorate quickly, and their needs are immediate.

This again is where the business of health care is not a business at all. This is where a nurse finishes a shift all rubber-legged, and pours himself or herself in the car for the drive home. Perhaps this helps explain the current national RN-turnover rate of 18.5 percent.

Some conundrumsSo conundrum number one is how much it will cost, or not cost (millions to be saved, according to the MNA) to staff hospitals at a level that minimizes understaffing at the expense of overstaffing. With health care costs spiraling upwards, this seems like a question that might be better addressed by health care academics and definitive research, rather than at a heated contract negotiation, where other issues are at stake. Interestingly, although hospitals are highly regulated, there are no federal or state-mandated hospital staffing guidelines (except in California, where the results have been contentious). Hospitals decide for themselves individually, unless a union makes it a contract issue.

Conundrum number two is, as Wheeler put it, how do we find “the right staffing to meet the patients’ needs.” Put more simply, can some of what nurses do be relegated to lower-wage employees such as nursing assistants?

Ken Paulus

“Are we using nurses, as Ken Paulus [Allina CEO] says, at the highest level of their license?” Wheeler asked. “Should a nurse do the coordination planning for a discharge, or should we have a team member do that? Should a nurse have to run around and get bed sheets for a bed?

“If you staff to these certain levels that are very prescriptive, and tell you how to do it, does that give you any ability to affect the care team around the patient and let people use their unique skills most effectively?”

“Most effectively.” Here are two words that need to be a much more integral part of any attempt to trim down our country’s bloated, high-cost, average-outcomes health care system. Be it nursing ratios, blood pressure medications, cancer screening, etc., on multiple levels we need to identify those things that really have proven value to our health, and let go of the rest. A well trained, unharried RN at your hospital bedside might be a very good value, and perhaps a whole lot more benefit to you than the “Gizmotron 8000” that the hospital just purchased to stay competitive.

The days of hospital care being provided by nuns and bake sales are far behind us. The MNA understands the competitive nature of today’s health care, but they think nursing care is a great value and good for business (ie. patients).

“I think the frustration our nurses feel is that the hospitals are doing a very good job with their PR campaign of saying ‘We’re non-profit. We’re struggling along,'” Nemo told me. “But the reality is, they’re in a system where they do operate like a for-profit entity because they have to compete.

“I think everybody gets that, but it’s frustrating for the nurses who are on the front lines to see that new center open up at Abbott [Northwestern Hospital] with all the feng shui and go, ‘But you’re telling me I can’t have another nurse on this day when we’re slammed?’ Come on, where’s the priorities?”

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Comments (1)

Dr. Bowron,
First of all, very well stated summary of the current factors impacting each side’s impasse on the negotiation. Regarding conundrum number one, speaking as a Registered Nurse, recently released data have the hospitals (as a whole) involved in the dispute with the union showing a fiscal yearly profit of over 750 million dollars. While this is great for the individual hospitals, I would add that a possible way they have increased profitability has been at the expense of the direct providers of care. The hospitals have cut back on staffing of other members of the team that could provide the assistance necessary to allow the Nurse to operate on the highest level of their license as stated above in conundrum number two. For example, there has been increases over the past few years of the nurse per patient ratio along with a decrease in the number of nursing assistants and a cut in the hours per day of the unit secretary to 8 -12 hours a day maximum. This is likely a positive correlate between both the hospitals ability to profit over 750 million dollars and the increased impact on the nurses ability to provide higher quality of care. I compare it to the stretching of rubber band to the limit and beyond, and just waiting for the snap. I have heard other’s compare it to Starling’s Law.
The proposed contract has contained in it several components that would directly remove the nurses ability to use judgement, when needed, to provide safe care. For instance, the proposal removes the ability to close a unit in cases of extremely high acuity for 4 hours to further admissions, it also removes the ability to mediate a grid review which is a portion where the concerned staff and management can negotiate the levels of staff needed based on census levels and then create the grid matrix used for the year.
I have looked at the Aiken article you cited above as well as the California article the hospitals cite regarding no correlation between staffing level and patient outcomes. The problem that I see in the studies are that the hospitals cite a study that assessed the outcomes based on data from management, the Aiken study data is obtained from nurses, both then lead me to believe that possible bias may be impacting outcomes from the research. My hope as an RN in this contract negotiation is that the sides come to agreement on the issues so that the ability to provide the highest level of patient care is at a minimum kept at the same level!